| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,148 |
1,142 |
$44K |
| D1110 |
Prophylaxis - adult |
384 |
379 |
$25K |
| D1120 |
Prophylaxis - child |
896 |
889 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,026 |
1,020 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
223 |
218 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,979 |
1,353 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,077 |
958 |
$6K |
| D0272 |
Bitewings - two radiographic images |
797 |
788 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
55 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
14 |
$1K |